Florence Ip, MD
Pediatric/Anesthesiology Resident
Boston Children's Hospital
Boston, Massachusetts
Disclosure information not submitted.
David Zurakowski, PhD
Associate Professor
Boston Children's Hospital, United States
Disclosure information not submitted.
David Kantor, MD
Boston Children's Hospital
Boston, Massachusetts
Disclosure information not submitted.
Title: Echocardiography in the Management of Pediatric Shock is Followed by Changes in Vasoactive Strategy
Introduction: The Pediatric Surviving Sepsis Guidelines recommend advanced monitoring (such as echocardiography) to tailor vasoactive strategy to shock type. However, evidence is lacking to demonstrate that in routine practice 1) clinicians respond to echocardiography by changing vasoactive strategy, or 2) a mismatch between shock type and vasoactive strategy results in worse outcomes. The goals of this study are to examine whether vasoactive strategy changes following echocardiography and if matching vasoactive strategy to shock type is associated with differences in lactate clearance.
Methods: This is a retrospective case control study for patients age 1 – 18 years who had formal echocardiography within 72 hours of ICU admission over ten years from 2011 - 2020. Data regarding vasoactive agents was abstracted from the EMR for the 36 hour period before and after echocardiography. Patients were divided into the following groups: 1) normal/mild, with normal LV function or mild LV dysfunction, and 2) moderate/severe, with moderate to severe LV dysfunction.
Results: The normal/mild group (n= 152) and the moderate/severe group (n = 97) were statistically well-matched by age, race, diagnoses, and pSOFA scores. Among the normal/mild group, the percentage of patients treated with an inotrope strategy significantly decreased from 43% to 22%, while those treated with a vasoconstrictor strategy significantly increased from 38% to 53% in the 36 hours following echo. In contrast, among the moderate/severe group, the percentage of patients treated with an inotrope strategy significantly increased from 42% to 47%, while those treated with a vasoconstrictor strategy significantly decreased from 43% to 19% in the 36 hours following echo. Among the moderate/severe group, those treated with an inotropic strategy demonstrated significantly greater lactate clearance compared to those treated with a vasoactive strategy after adjusting for disease severity.
Conclusion: Vasoactive strategy in pediatric shock changes significantly in the 36 hour period following echocardiography in a manner which reduces the mismatch between vasoactive strategy and shock type. Further, mismatch between vasoactive strategy and shock type is associated with significantly impaired lactate clearance among those patients with moderate to severe LV dysfunction.